Failure to Use Appropriate Oxygen Delivery Device During CPR
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to use the appropriate oxygen delivery device during cardiopulmonary resuscitation (CPR) for a resident who was unresponsive, had no pulse, and was not breathing. Instead of using a bag valve mask (Ambu bag) to provide positive pressure ventilation, the LVN placed the resident on a non-rebreather mask at 10 liters of oxygen. The non-rebreather mask is not designed for use on individuals who are not breathing, as it cannot deliver oxygen without the patient’s own respiratory effort and may obstruct the airway. The resident involved had a medical history including diabetes mellitus, chronic obstructive pulmonary disease, and hypertension, and was admitted to the facility with a full code status, as indicated by the Physician Orders for Life-Sustaining Treatment (POLST). On the day of the incident, the resident was observed having convulsions, became unresponsive, and was found to have no pulse and was not breathing. CPR was initiated, but the LVN used a non-rebreather mask rather than the Ambu bag, contrary to facility policy and standard emergency procedures. Emergency medical services (EMS) were called and arrived shortly after, but the resident was pronounced dead. Interviews with facility staff, including the LVN involved, the Director of Nursing (DON), and other nurses, confirmed that the correct procedure during CPR for a non-breathing resident is to use an Ambu bag to provide positive pressure ventilation. The facility’s policies and national guidelines also specify the use of a bag valve mask in such situations. The use of a non-rebreather mask on a non-breathing resident was acknowledged by staff as inappropriate and potentially obstructive to oxygen delivery.